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Posttraumatic Stress Disorder After Minor Trauma – a Prospective Cohort Study T Medical Hypotheses 135 (2020) 109465 Contents lists available at ScienceDirect Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy Posttraumatic stress disorder after minor trauma – A prospective cohort study T Katharina Angerpointnera, Stefanie Weberb, Karen Tschechb, Hannah Schubertb, Tanja Herbsta, ⁎ Antonio Ernstbergera, Maximilian Kerschbauma, a Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany b AARU Audi Accident Research Unit, University Hospital Regensburg, Regensburg, Germany ARTICLE INFO ABSTRACT Keywords: Background: Posttraumatic stress disorder (PTSD) can arise as a reaction to a traumatic experience. While many Posttraumatic stress disorder data concerning PTSD in severely injured patients are available, little is known about this disease in slightly PTSD injured patients after road traffic accidents. It is rather assumed that PTSD does not exist after objectively slight Anxiety disorder injuries. Minor trauma Methods: In total, 36 patients (Injury Severity Score < 16) after road traffic accidents were included in this Road traffic accident prospective cohort study. Next to demographic and accident-specific data, the PDI (Peritraumatic Distress Inventory: individual experienced distress directly during or immediately after the traumatic event), THQ (Trauma History Questionnaire) and the BDI-II (Beck Depression Inventory-II: self-report measurement tool to examine the severity of depression) were assessed immediately after trauma (t0). Six weeks (t1) and 3 months (t2) after trauma the Impact of Event Scale – Revised (IES-R), a screening instrument for PTSD, and the BDI-II were collected. Results: Overall 2 patients showed critical measurement values in IES-R after 6 weeks. A strong correlation between PDI and IES-R at t1 and t2 could be detected (p < 0.05). Furthermore, a significant correlation of BDI- II and IES-R after 6 weeks and 3 months was found (p < 0.05). Neither age or sex showed a significant corre- lation to IES-R (p ≥ 0.05). Conclusion: The present study showed that symptoms of PTSD can also occur after minor trauma. Especially high peritraumatic distress is associated with developing a PTSD. The occurrence of PTSD should be considered not only in severely injured patients, but also in slightly injured patients after road traffic accidents. Background hyperarousal. The symptoms have to last longer than one month, cause significant functional impairment and develop within the first 6 months Posttraumatic stress disorder (PTSD) is a widespread form of anxiety after trauma [2]. disorder. It arises as a reaction to the experience of a traumatic situation Many studies investigated possible influencing factors for devel- and a subsequent maladaptation. To diagnose PTSD according to the oping a PTSD [3–7]. The results showed that injury severity is not a Diagnostic and Statistical Manual of Mental Disorders, 5th edition good predictor of psychosocial outcome, whereas the subjective impact (DSM-5) [1], a patient has to experience a traumatic event and addi- of trauma is much more important in this context [7]. Recent studies tional symptoms from each of the following four symptom clusters: have shown that a traffic accident can be a triggering event for devel- intrusion (e.g. flashbacks, nightmares), sustained avoidance of trauma- oping PTSD [2,8,9]. The prevalence of PTSD in severely injured patients associated stimuli, negative impact on cognition/mood and ranges from 4.7% up to 34% within the first three months [10,11]. But Abbreviations: AIS, Abbreviated Injury Scale; BDI-II, Beck Depression Inventory-II; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; GCS, Glasgow Coma Scale; ICU, Intensive Care Unit; IES-R, Impact of Event Scale-Revised; ISS, Injury Severity Score; MAIS, Maximum Abbreviated Injury Scale; PDI, Peritraumatic Distress Inventory; PTSD, Posttraumatic stress disorder; SD, Standard Deviation; t, time; THQ, Trauma History Questionnaire ⁎ Corresponding author at: Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany. E-mail addresses: [email protected] (K. Angerpointner), [email protected] (S. Weber), [email protected] (K. Tschech), [email protected] (H. Schubert), [email protected] (T. Herbst), [email protected] (A. Ernstberger), [email protected] (M. Kerschbaum). https://doi.org/10.1016/j.mehy.2019.109465 Received 9 September 2019; Accepted 27 October 2019 0306-9877/ © 2019 Elsevier Ltd. All rights reserved. K. Angerpointner, et al. Medical Hypotheses 135 (2020) 109465 so far, this research was only focused on PTSD after severe injury and Table 2 polytrauma. The aim of the following study was to determine whether Timetable for data collection and questionnaire. ffi PTSD is likely to develop in lightly injured patients after road tra c t0: Immediate after trauma t1: 6 weeks after t2: 3 months after trauma accidents and to determine possible predictive factors to detect high- trauma risk patients in clinical practice. PDI IES-R IES-R THQ BDI-II BDI-II Hypothesis BDI-II Patients can develop Posttraumatic Stress Disorders (PTSD) even if PDI: Peritraumatic Distress Inventory; THQ: Trauma History Questionnaire; – they are only slightly injured after a traffic accident. The subjective BDI-II: Beck Depression Inventory; IES-R: Impact of Event Scale Revised. experience of the accident seems to be mainly relevant to the devel- Peritraumatic Distress Inventory (PDI) [15] opment of an affective disorder like PTSD – regardless of the severity of the injuries. The PDI is used to estimate the individual experienced distress di- rectly during or immediately after the traumatic event [15]. The 13- Methods items test concerns fear or helplessness and physical response reactions. A result of 23 points or more is considered as critical threshold [16]. Study population Trauma History Questionnaire (THQ) [17] Adult trauma patients (18–65 years) with minor injuries (Injury ffi Severity Score: ISS < 16 [12]) after road tra c accidents were in- This 24-items questionnaire is used to examine individual experi- cluded in this prospective cohort study. Trauma room patients were ences with potentially traumatic events like crime, general disaster and excluded. sexual or physical assault prior to the accident using a yes/no format For inclusion, the patients had to remember the sequence of events [17]. As the THQ is considered to be a history data collection instru- and the cause of accident. The Glasgow Coma Scale (GCS) [13] had to ment, the THQ has a qualitative result and there is no standard scoring fl be 15 at all times. Patients under the in uence of drugs or alcohol and method. ones who lost consciousness, had to be intubated or with Intensive Care Unit (ICU) stay after trauma, were excluded. Table 1 summarizes the in- Impact of Event Scale – Revised (IES-R) [18] and exclusion criteria. In total 69 patients met the in- and exclusion criteria. Due to in- The IES-R is a screening instrument for PTSD and consists of 3 complete data (participation declined, missing accessibility, contra- components: intrusion (7 items), avoidance (8 items) and hyperarousal (7 dictory information in the questionnaires) 33 patients were not avail- items) [18]. Based on a formula published by Maercker and Schützwohl able for follow-up. In total, 36 patients were included in this study. [19], a cumulative score can be formed from the three components to estimate the probability of developing a PTSD. The single dimension Data collection values lie within a range of 0–35 points and the total score is calculated from the dimensions following a rather non-linear principle. In case of In this prospective cohort study data collection was performed values higher than 0.0, PTSD can be expected. It should be noted that within 4 days, 6 weeks and 3 months after trauma [10]. Immediately IES-R is a screening tool to facilitate the assessment of typical PTSD after trauma (t0) demographic and accident-specific data were re- symptoms and cannot be used to determine the actual existence of corded. Additionally, the Peritraumatic Distress Inventory (PDI), the PTSD. Nevertheless, a high degree of intercorrelation and internal Trauma History Questionnaire (THQ) and the Beck Depression In- consistency have been reported for this questionnaire [20,21].Different ventory (BDI-II) were collected. After 6 weeks (t1) and 3 months (t2) studies describe the IES-R as an appropriate tool for PTSD screening the patients had to complete the Impact of Event Scale – Revised (IES-R) with a high predictive value [19,22–24]. and the BDI-II. The questionnaires used are explained below. Table 2 shows the timetable for data collection and questionnaire. Beck Depression Inventory-II (BDI-II) [22] Demographic and accident-specific questionnaire The Beck Depression Inventory-II is a widely used self-report mea- surement tool to examine the severity of depression in adolescents and Age, sex, graduation, current employment situation, medical history adults. The 21-item self-report inventory indicates severity of depres- including psychological disorders and regular medication and drug or sion, with higher scores indicating greater depression. Values from 14 alcohol consumption were collected. Additionally, details concerning to 19 points indicate a mild, 20 to 28 points a moderate and 29 to 63 the accident, the injury pattern (Maximum Abbreviated Injury Scale points a severe depression [22,23]. (MAIS) [14]; Injury Severity Score (ISS) [12]) as well as the estimation of recovery chances and the issue of guilt were recorded. Ethical considerations Table 1 The study has been approved by the Ethics Committee of the In- and exclusion criteria. University of Regensburg (number 16-101-0113). The study database was completely anonymized at the end of the investigation. Inclusion Exclusion 18–65 years GCS < 15 Statistical analysis ISS < 16 Anterograde or retrograde amnesia Road traffic accident Unconsciousness All analyses were performed by using IBM SPSS Statistics 22.0 (IBM fl Full memory of the accident In uence of drugs or alcohol Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0.
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